Quality Assessment and Performance Improvement

(A) A Program shall develop and implement an ongoing, program-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program. (B) A Program shall form a QAPI committee to implement the QAPI program. (1) The QAPI committee shall include at least the Program Director, a registered nurse employed by the program, and one or more individuals appointed by the Program Director. (2) The QAPI committee shall meet at least two times per year and shall maintain minutes of all meetings. (C) The QAPI program shall measure, analyze, and track quality indicators, including adverse events and other aspects of performance that enable the Program to assess the quality of Program services and operations. (D) The QAPI program shall collect quality indicator data in order to: (1) Monitor the effectiveness of services; (2) Monitor quality of care at the Program; (3) Monitor safety at the Program; and (4) Identify opportunities and priorities for improvement. (E) The QAPI program's activities shall: (1) Focus on high risk, high volume, or problem-prone areas; (2) Consider incidence, prevalence, and severity of problems in those areas; (3) Positively affect participant safety and quality of care; (4) Track adverse participant events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the Program; (5) Take actions aimed at performance improvement; and (6) Measure success and track performance to ensure that improvements are sustained. (F) QAPI Projects. (1) QAPI programs must develop, implement, and evaluate performance improvement projects. (2) The number of QAPI projects shall be based on the needs of the Program's population and internal organizational needs, and must reflect the scope, complexity, and past performance of the Program's services and operations. (3) The QAPI program shall document the performance improvement projects it conducts, the reasons for conducting the projects, and the measurable progress achieved on the projects. (G) The Program Director shall be responsible for the following: (1) Ensuring that the QAPI program reflects the complexity of the Program's organization and services, involves all Program services, focuses on indicators related to improved outcomes, and exhibits improvement in Program performance; (2) Approving the frequency and content of the data collection; (3) Obtaining, reviewing, and acting upon the findings of the QAPI Committee; (4) Ensuring that the QAPI program efforts address priorities for improved quality of care and participant safety, and that all improvement actions are evaluated for effectiveness; (5) Preparing and submitting a report to the Participant and Family Advisory Council that details QAPI program activities and projects at least two times per year; and (6) Responding to the Participant and Family Advisory Council feedback regarding the QAPI program. (H) The QAPI program must be capable of showing measurable improvement in indicators related to improved outcomes and Program services.